GW1--01177_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: :
Kolby Mitchel Sawyers
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4471-A `
ft. ft.
NC Well Contractor Certification Number
.15`:()tiTERCASit4C,.(fdrtnntd caseilir•eifiRil'L`[NECt(if"up ifcable) A.
CLYDE SAWYERS &SON WELL & PUMP INC FROM TO DIAMMLF:R THICKNESS MATF:RIAI
+1 ft 37 ft. 6.25 ' in' #21 PVC
Company Name
2023-00313 itltSINZA,WINC. 0.1(N01(gCoiherrltilelecd-I soop)� nx2 .,ax.;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. I' in.
3.Well Use(check well use): ft. ft. in.
Supply
FROM TO Ynx d`Di.aMETERz'r.U.'�.ri:'a'� .v?`.Sba•`h %� e.�c''_) '..�a`.
Water Su ly Well: I
Agricultural ®Muiticlpal/PUhhC fllltVSREE ft. ft. in. SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
industrial/Commercial ®Residential Water Supply(shared) 18 GROUT i � >r' . .•. h .`
Irrigation Non-Water Supply Well:
FROM TO MATERIALI(MPLACFMItN'r MF:THOn&An10UN'1'
0 ft• 20 ft* Bentonite j, Pumped
Monitoring Recuvety ft ft. I Cap Top with Benlomile chips
Injection Well:
ft. ft.
Aquifer Recharge ()Groundwater Remediation u
#,19;SANDiGRAVEL PACK'(if iivphe#6le)D : ^. . 'y i tr
Aquifer Storage and Recovery 0 Salinity Barrier mom MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer .2O?D111T:1VNG'1 C1G{aitacliaddihOiiii sheet`sif>iecessari) 3 ' -WaW
FROM TO DESCRIPTION(color,hardness,soil/rock type.grail size.etc.)
0Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
0 ft. 37 ft. OVER BURDEN
4.Date Wells)Completed: 12-22-2023 Well iD# 37 ft' 905 ft' GRANITE ,
5a.Well Location: ft. ft. " '"' .7'.£Warren J Yeisley ft. ft. %,Z.: .iz. w► �,,
Facility/Owner Name Facility ID#(if applicable) ft. ft. FE6
215 Whitaker Road Fairview, NC 28730 ft. ft. ;i ' CQZ
ft. CL 1SIL",r,btif[Cil_,rr+i t
Physical Address,City,and Zip . '`f"a.t pt
Buncombe 969638603300000 32:1 0EHMSN �' ';'. '!4 ._:AR�X �' .,- ''
County Parcel Identification No.(PiN) W II was self certified
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N VI' !
1-5-2024
6.ls(are)the well(s)�IX.. Permanent or Temporary Signs a of et ed onaador Date
By signing di Om,1 hereby yet. j•that the well(s)was(were)constructed in acea•dance
7.Is this a repair to an existing well: ljYes or %INo with 1SA NCAC 02C.0100 or ISA NCAC 02C'.0200 Well Construction Standards and that e
If this is a repair.fill out known well construction information and explain the nature of the copy of this record has been provided to the,,well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjarent(example-3@200'and 2(a 100') construction to the following: I
10.Static water level below top of casing: 180 (ft.) Division of Water Resources,;rnformation Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: in additi h to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: RIG 24c.For Water Supply&lniectionL Qelis: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PILLS Amount: 35 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016